How we can improve HIV testing and counselling

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On Friday 16 March 2012 health workers, counselling organisations, activists and the National Department of Health met in Hillbrow to discuss how to improve HIV testing and counselling. The meeting was hosted by the Southern African HIV Clinicians Society, the Treatment Action Campaign and SECTION27.

The above-signed organisations agree that:

Every sexually active person should volunteer to get tested for HIV.

People who test HIV-positive should receive the information they need to protect their health.[1] They should also be kept in the health system and be referred for CD4 counts so that they can initiate antiretroviral treatment when necessary. People who test negative should be advised on HIV prevention, given male or female condoms and encouraged to test again at least once a year.

Counselling and testing children has a unique set of complexities, though much work has been done to establish guidelines in this area.[2]

In 2010, Health Minister Motsoaledi launched a massive HIV counselling and testing campaign. Over ten million people were tested, but still too many people do not know their status. Far too many people present to the health system when they are very ill with low CD4 counts. Also, far too many who test HIV-positive do not receive essential advice and are not kept in the health system.

When people go to a health facility, they should routinely be offered HIV testing. It should always be easy to be tested for HIV and a tested person should always be provided all the information he or she needs to stay or become healthy.

Most people find HIV testing stressful; it is vital that health workers always treat their clients with respect. The confidentiality of HIV test results must be assured. But SANAC and the government must work to create a social environment where more people can voluntarily disclose their HIV status, particularly to trusted friends and family.

There are serious problems with the quality of both counselling and testing. For example, one study followed over 260 rapid test processes in the public health system. It found that less than 4% of these complied with guidelines.[3] Counsellors across the country are giving vastly different advice to patients and administering different HIV testing protocols of varying quality. The poor quality of counselling and testing causes low rates of linkage to care after testing.

Counsellors should be provided a testing checklist or algorithm, along with effective training and support, to improve their ability to consistently convey the correct essential advice to clients. The checklist or algorithm should be short and easy-to-understand, available in all languages, so that all counsellors can read and implement it. Checklists and algorithms do not preclude counsellors from showing empathy to their clients. Examples of tools for improving counselling were presented to the meeting.[4]

During the next few years, algorithms and checklists should be tested scientifically and ultimately standardised based on empirical findings. Counsellors are managing the often highly complex psychosocial issues of patients in healthcare facilities. Standards for mental health screening and referral should be developed and implemented and counsellors trained on managing critical common mental health problems that are pervasive in patient populations.

Quality of HIV tests

The quality of rapid HIV tests varies considerably. There is no clear monitoring and evaluation mechanism in place to ensure the reliability and ease of use of HIV diagnostic tests once they are widely distributed, nor a clear mechanism for health care workers to report concerns over the ease of use or reliability of newly introduced HIV rapid tests. Routine monitoring and evaluation of these tests should be performed at clinics and other rapid testing sites to ensure high levels of sensitivity and specificity.[5]

Manufacturers and distributors of HIV rapid tests must disclose any problems with their products that affect sensitivity and specificity, so that a particular test can be pulled from use until the problem is resolved.

This also raises the urgent need to regulate all medical devices to ensure their quality, safety and efficacy.

The role of management

Managers of health facilities are responsible for the quality of testing and counselling. They must:

Implement routine monitoring and evaluation of counsellors to ensure that they carry out test protocols properly and provide clients with accurate, essential information.

Ensure that clients who test HIV-positive can have a CD4 count, whether that is immediately at the testing site, which is ideal, or via referral by the counsellor to another facility.

Only allow high quality approved HIV tests with high sensitivity and specificity to be used.

Ensure that counsellors give high-quality approved condoms to all people who get tested.

Ensure that HIV test results are kept confidential.

Ensure that testing sites have adequate physical space to provide a confidential service.

Health facilities should also offer TB screening and psychosocial support for people who test HIV-positive. However, we recognise that only a fraction of facilities can currently do this because of a lack of resources in the public health system. HIV testing and treatment should take place even when these services are not available.

Employment of counsellors by the Department of Health

Many counsellors receive stipends, not salaries, and their employment status is uncertain. Counsellors provide a critical service and must be valued.

We say that the casualisation of HIV counselling must be phased out and all counsellors should be formally employed. Counsellors working in the public health system should be employed by the Department of Health and have career paths. An appropriate screening process of applicants for counselling posts should be developed so that people who possess the qualities needed to be effective HIV counsellors are more likely to be hired.

Employment of HIV counsellors must include a clear job description outlining the duties of the job and criteria on which their performance will be evaluated. Routine performance evaluations should be conducted and used to identify gaps that require additional training and support.

Home and HIV self-testing

There are many HIV rapid tests that are accurate and reliable if they are performed correctly, whether they be performed at a health facility by a trained health care worker or via alternative methods such as large community-based testing events, home-testing by health care workers and, more recently, HIV self-testing.

These are all now a part of the HIV testing landscape, with an increasing number of studies reporting positive outcomes, including high uptake rates and accuracy. These additional testing options will augment the reach of standard facility-based testing, and are an opportunity for wide scale-up of testing.

The meeting agreed that to ensure good outcomes for alternative testing methods, particularly HIV self-testing, tests that are being sold must meet quality standards and must be safe and easy for people to use.[6] Research on this is being done.

It is essential that introduction of HIV self-testing be accompanied by the same essential components of any HIV testing service, including easy access to accurate information especially linkage to care for those who test positive. It is vital to have systems and public information that guards against abuse and misuse of self testing in a home environment, particularly of women and children. The national AIDS helpline should provide this service. Counsellors on this line must receive updated training and information to enable them to assist callers through the testing process including interpretation of results, and to refer people who test positive, to their nearest Department of Health clinic or hospital for CD4 counts.

Conclusion

We recognise that it will take several years to standardise counselling and testing. But improvements to HIV testing and counselling can be implemented immediately by diligent health facility managers, training institutions and counsellors. Providing a high quality HIV testing and counselling service is possible; many facilities already do it.

We will consult further, refine our recommendations based on feedback and drive the process to improve testing and counselling.

[1] This includes: (i) the importance of checking your CD4 count every six months; (ii) the benefits of starting antiretroviral therapy if your CD4 count falls below 350 cells/mm^3 on at least two readings taken one month apart, or if you have an AIDS illness; and (iii) the symptoms of tuberculosis and how your clinic will diagnose it.

[5] This is especially important after a new HIV rapid test is introduced. that changes the way the test is actually performed, such as duration of incubation, number of drops of developer, or introduction of wiping finger with alcohol before blood is transferred to the cassette.

[6] The current legal and policy framework should urgently be amended to include specific provisions on self-testing kits and to remove all provisions that would prohibit their distribution. Once the South African Health Products Regulatory Authority is in place, a suitable regulatory system for all diagnostic tests, including self-tests for HIV, needs to be created. The information sheet in a self-testing kit should contain detailed but simple information on HIV-testing with an emphasis on explaining the window period and the importance of confirming a positive HIV result at a clinic or hospital where appropriate management of HIV could be offered. Self-testing kits should clearly display the accuracy of the test and emphasise the importance, in unambiguous language, of the need for a confirmatory test of a positive result. The information sheet in the testing kits should recommend that the user contact a toll-free helpline for counselling and assistance when taking the test. Existing telephone helplines like the National AIDS Helpline and LifeLine should expand their services to include counsellors who have been trained to counsel people who conduct home tests and who can make the necessary referrals